1. Thad Q. Strom, Ph.D. Minneapolis VAMC

2. Acknowledgments Thank you to Drs. Michael, Anestis, and Siegel for input and guidance on the following slides.

3. Objectives Following this presentation, participants will be able to: Discuss sociocultural factors that impact suicide assessment within the VA Describe the concepts of the Interpersonal Psychological Theory of suicidal behavior Describe risk factors for suicide Successfully assess and document suicide risk level

4. Agenda Brief discussion of interaction between VA related suicide, the media, politics and clinical care. Overview of the Interpersonal-Psychological Theory of Suicidal Behavior Review of a framework for determining suicide risk level Briefly review documentation and VA suicide prevention initiatives

5. Suicide 34,000 US deaths annually 1 every 16 minutes Approximately 93 per day Approximately 20% are veterans (April 2010, DVA Fact Sheet) 11 th leading cause of death in US 8 th for males (19 per 100,000) 16 th for females (5 per 100,000) 2 nd leading cause of death in college students (3 rd for age 10-24) More common than death by homicide 8.5-25 attempts for every death by suicide Approximately 5,000,000 individuals in US have attempted CDC, 2007

6. Suicide Sex differences Men substantially more likely to die by suicide than women White males over 65 years of age at greatest risk Women three times more likely to attempt 67% of male suicide deaths by firearms; 33% for women CDC, 2007

7. What do you assess for suicide risk? What have you learned to assess for thus far in your career? Why have you been told it is important to assess these things?

8. Interpersonal-Psychological Theory of Suicidal Behavior (IPTS) Thwarted Belongingness Capability for Suicide 1.Perceived Burdensomeness Makes no valuable contributions to world 2.Thwarted Belongingness Has no meaningful connections to others 3.Acquired Capability for Suicide Habituation to physiological pain and fear of death Desire for Suicide Joiner, 2005 Perceived Burdensomeness Lethal (or near lethal) Suicide Attempts

9. IPTS – Empirical Support Burdensomeness * Belongingness  Suicidal Ideation (Joiner et al., 2009; Van Orden et al., 2008) Acquired Capability for Suicide associated with… Lifetime number of painful and provocative events (Van Orden et al., 2008) Lifetime number of suicide attempts (Van Orden et al., 2008) Range of combat experiences encountered by military personnel deployed in Operation Iraqi Freedom (Bryan et al., 2010) PTSD re-experiencing symptoms (Bryan & Anestis, in press) Higher in military samples than in civilian clinical and non-clinical samples (Bryan, Anestis, Morrow, & Joiner, 2010; Selby, Anestis, et al., 2010) 3-way interaction of IPTS Components  Clinician-rated suicide risk (Joiner et al., 2009) Lifetime number of suicide attempts (Van Orden et al., 2008) Adapted from a slide from Michael Anestis

10. Determining Risk: A Framework Seven domains of risk factors have been proposed: Previous suicidal behavior Nature of current suicidal symptoms Precipitant stressors General symptomatic presentation Presence of hopelessness Impulsivity and self-control Other predispositions Protective factors Joiner, Walker, Rudd, & Jobes, 1999

11. Previous Suicidal Behavior The most important domain for risk assessment Some evidence of important differences between: Suicide ideators Single attempters Multiple attempters For multiple attempters, the baseline risk will always be elevated. History of attempts is always evaluated in conjunction with other risk domains.

12. Nature of Current Suicidal Symptoms Divided into two factors: Resolved plans and preparation Ex: Feeling competent and courageous to make attempt, availability of means and opportunity, duration and intensity of ideation. Suicidal desire and ideation Ex: Reasons for living, wish to die, frequency of SI, talk of death and/or suicide. While frequency of SI is noteworthy, intensity and duration of SI is a more pernicious indicator.

13. Precipitant Stressors Important to assess for recent life stressors Particularly those involving interpersonal loss and disruption Ex: relationship disruption, legal troubles, physical/emotional abuse Attempt history tends to affect the duration of suicidal symptoms following crisis. Even non-attempters may develop SI in the face of life crises, but the duration of this crisis is likely to be shorter.

14. Risk Factors (cont’d) General Symptomatic Presentation Including Hopelessness Review the presence and severity of Axis I and Axis II symptomatology. Perhaps the most commonly reviewed through grad school training Impulsivity and Self-Control Impulsivity tends to be a trait factor that is present throughout a person’s life Other Pre-disposing factors Chaotic childhood, sexual/physical abuse

15. Protective Factors Social support Self-perceived quality of social support Self- control and problem-solving ability These do not negate serious risk factors (e.g., multiple attempts) but may help determine level between categories.

16. Determining Risk: A Continuum Presence of multiple attempts in conjunction with other risk factors determines severity. Severity Ratings: Non-existent No identifiable suicidal symptoms, no past history, and no or few other risk factors Mild Multiple attempter with no other risk factors, OR A nonmultiple attempter with SI of limited intensity and duration, and No or mild planning/resolution, and No or few other risk factors Joiner, Walker, Rudd, & Jobes, 1999

17. Determining Risk: A Continuum Moderate A multiple attempter with any other notable finding, OR A non-multiple attempter with severe to moderate preparation and resolution Severe Multiple attempter with any two or more notable findings Non-multiple attempters with significant preparation/plans and at least one other risk factor Extreme

18. Graphic Representation Multiple Attempter? Yes No Resolved Plans & Preparation? Any other significant risk factor = AT LEAST Moderate Risk YesNo Any other significant risk factor = AT LEAST Moderate Risk Suicidal Desire & Ideation? No Yes Two or more other significant risk factor = AT LEAST Moderate Risk Joiner, Walker, Rudd, & Jobes, 1999

19. Documentation Progress notes No-show/cancellation notes Risk Flags Suicide behavior reports Safety Plans Standard disclaimer: If the risk assessment or outreach is not documented, then it is considered to never have happened!

20. No-shows and Cancellations  Consider outreach on a continuum:  Do nothing  Send a letter  (Try to) call the veteran  (Try to) call individuals for whom there is a signed release of information  Contact the sheriff’s department to arrange for a welfare check  Consider the potential effects of outreach attempts on the treatment and the therapeutic relationship  Generally better to err on the side of higher-level outreach

21. Suicide Behavior Report Necessary documentation when an attempt has been made, or there is a clinically relevant increase in risk for someone who has had a suicide behavior report noted previously. Reviewed and tracked by suicide prevention coordinator May lead to a suicide behavior flag in the veteran’s chart.

22. Suicide and the Media

23. VA Campaigns to Reduce Suicide Suicide Prevention Coordinators http://www.mentalhealth.va.gov/suicide_prevention/ Suicide Risk Flag in CPRS

24. Our Local Facility Let’s discuss some risk management procedures locally.

25. Links Military Suicide Research Consortium https://msrc.fsu.edu/ Psychotherapy Brown Bag www.psychoterapybrownbag.com National Institute of Mental Health www.nimh.nih.gov Substance Abuse and Mental Health Services Administration (SAMHSA) www.samhsa.gov National suicide prevention number: 1-800-273-TALK Suicide Prevention Resource Center www.sprc.org